PERCUTANEOUS TREATMENT OF FACET JOINT SYNOVIAL CYST DEVELOPPED IN INTRA DUCTAL - PowerPoint Presentation

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PERCUTANEOUS TREATMENT OF FACET JOINT SYNOVIAL CYST DEVELOPPED IN INTRA DUCTALS. KOUKI ,W. AMORRI, M. LANDOULSI , S. BOUGUERRA , Y.AROUS , H. BOUJEMAA , N. BEN ABDALLAHMilitary Hospital of Tunis

INTV3

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objective:To study the results of facet joint intraarticular steroid injections in a patient with symptomatic lumbar facet joint synovial cysts developped in intra ductal.

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IntroductionFacet joint synovial cyst is an Expansion of the joint capsule and synovium into the spinal canalBy definition it communicates with the adjacent jointThe average age when it occured is 60 years It‘s a rare cause of radicular pain

Clinical signs are unilateral nerve root or radicular claudication bilateral lower

Is easily diagnosed by new medical imaging modalities

Image-guided percutaneous steroid injections presents often an effective alternative to surgery

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Case reportThe patient is a 59-years womanWithout individual medical history outside of an overweight complaining of low back sciatica type left L5, associated with a left cruralgia, refractory to medical treatment

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exploration by imagingRadiographs of the lumbosacral spine : a degenerative spinal disco, more advanced at L4-L5 segment, associated with a degenerative Low-grade isthmic spondylolisthesis.The CT scan : an intra ductal synovial cyst, next to the left posterior facet joint L4-L5, measuring 2cm long axis, which causes a conflict with the L5 root at its emergence, and L4 ipsilateral root.

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therapeutic managementA well conducted medical treatment with rest did not lead to a favorable outcome. A surgical treatment proposed refused by the patientShe was entrusted to us for a percutaneous treatment

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percutaneous treatment under scanner1/ installation of the patient, and tracking:

The patient

is

prone

positioned

.

The

procedure

is

performed

in the

interventional

scanner room

We

conducted

a

helix

centered

on the

lumbar

spine

to

identify

the

left

facet

joint L4-L5.

The CT

features

of the

facet

joint synovial

cyst

is

a

Rounded

picture

of

homogeneous

fluid

density

intra

ductal

with

hyper dense

fibrous

shell

.

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2/ PROGRESS OF interventional gesture:After local anesthesia and surgical skin

disinfection

Joint aspiration and injection of 1 ml of

iodinated

contrast

in

facet

joint,

opacified

both

the joint and the

cyst

intra canal,

objectifying

the communication

between

them

.

fluid

content

was

aspirated

Then

we

have

inject

a bulb of a

prolonged

action

corticosteroid

(

Altim

®)

combined

with

1cc of

Xylocaine

®

under

pressure

until

rupture of the

cyst

, as

evidenced

by a

loss

of

strength

and opacification of the

epidural

space

on the acquisition of control.

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Fig 1: Axial CT scan of L4 in bone window showing the average load of intra ductal cyst with mass effect on the dural sheath

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Fig 2: Axial CT scan of L4 in bone window showing the complete filling of the cyst with early extra vasation of contrast

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Fig 3 : Axial CT scan of L4 in bone window showing the complete filling of the cyst with clear extravasation of contrast material by cracking cystic

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Fig 4 : Sagittal reconstructions showing opacification and signs of intra ductal cyst

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3/ result and evolution:Immediately, the patient describes an exaggeration of pain

followed

by a relief

This

is

likely

due to the

effect

of

Xylocaine

® and the

reduction

of pressure in the

cyst

after

its

cracks.

This cracking

is

a cure of

this

cyst

,

it

is

evidenced

by the extravasation of

contrast

outside

the

cyst

.

The

decline

in

two

years

was

marked

by a favorable

clinical

course,

especially

since

the patient has

lost

weight

and

always

wore

a

lumbar

corset.

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Discussion1/ Pathophysiology (1)(4):

It’s a manifestation of progressive posterior facet

arthrosis

: during outbreaks of effusion, the normal joint recess become

diverticula

,

synovial

recesses

would

enlarge

with progressive fibrous thickening and inflammation of their walls.

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By definition, intraspinal synovial cysts communicate with the adjacent facet joint.

They

are

characterized

by the

presence

of synovial

lining

and

clear

or

xanthochromic

content

Opposed

to ganglion

cysts

that

do not

communicate

with

the

facet

joint, have a

fibrous

wall

, and

contain

gelatinous

myxoid

material

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Both entities often are described as juxta-articular or synovial cysts.Synovial cysts would be a manifestation of facet degeneration: The L4-5 level is most commonly involved because it corresponds to the level of maximal mechanical stress and motion.

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2/ imaging study (1)(2)(3)(4):CT-arthrography can

identified

synovial

cysts

communicating

with

the adjacent

facet

joint

with

marked

degeneration

and a

spondylolisthesis

Diagnosis

at

non

contrast

CT

is

based

on the

detection

of a

cystic

structure

next

to a degenerated facet joint, such as in our case. The cyst may

sometimes

extend

into

the

lateral

recess

.

The

presence

of

bony

erosions

or

remodeling

suggest

the

possibility

of

Tarlov

cyst

,

arachnoid

cyst

, or

cystic

nerve

sheath

tumor

, but

these

changes have

also

been

described

in patients

with

synovial

cysts

.

Facet

joint injection

demonstrating

communication of the

facet

joint

with

the

cyst

is

pathognomonic

for the

presence

of a synovial

cyst

.

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In the MRI signal is variable: * HypoT1, hyperT2: type fluid* HyperT1, hypoT2: type haem* HypoT1, hypoT2: gas, calcification, hemosiderin

* HyperT1, hyperT2:

blood

, fat

The

differential

diagnosis

includes

ganglion

cysts

,

posterior

longitudinal ligament

cysts

, and

ligamentum

flavum

cysts

;

however

,

these

cysts

do not

communicate

with

the

facet

joint and are not lined with epithelium.The cysts

often

are of

fluid

density

,

they

rarely

contain

blood

products

, calcium, or

gas

(

gas

in the

facet

joint).

The

presence

of

increased

wall

density

improves

diagnosis

and

narrows

the

differential

diagnosis

.

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3/ Type of therapeutic management :At the time of imaging, our patient had

already

undergone

medical

management,

combining

rest

and

NSAIDs

,

with

support

device

.

The

detection

of a

symptomatic

synovial

cyst

may

require

percutaneous

steroid

injection or

surgery

.

Surgery, performed initially, allows

resection

of the

cyst

and

treatment

of

other

potential

abnormalities

:

disk

herniation

, spinal

stenosis

,

narrowing

of the

lateral

recess

,

spondylolisthesis

.

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Long-term follow-up for surgical excision of symptomatic juxtafacet cysts without spinal fusion revealed

excellent to good

results

in 92% of the patients,

with

a satisfaction rate of 80%, in the

study

of

El

Shazly

AA.(3).

Common

surgical

risks

include

spinal

instability

, dural

tear

,

neurologic

injury

,

epidural

hemorrhage

and

hematoma

,

seroma

, and

cyst recurrence  While surgery is the gold standard for the treatment

for

symptomatic

facet

joint

cysts

, conservative options

include

bed

rest

,

physical

therapy

, acupuncture, oral

analgesics

and

anti-inflammatories

, and

percutaneous

injection and aspiration

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Arthrography-infiltration is a good alternative in case of cons-indication to surgery or refusal Percutaneous interventions are usually indicated in

elderly

or

high

-

risk

patients (1)(2)(3). 

Under image-

guided

assistance,

transforaminal

or

interlaminar

epidural

corticosteroid

and

anesthetic

injection

can

be

performed

pre

-

emptively

or

concurrently

to

reduce

the

risk

of

procedure

-

related

pain (1)(2)(3).

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In long-term follow, C Parlier-Cuau(6), in his study of 30 Patients, found that

One-third had long-lasting acceptable benefit,

and Bureau NJ(5) objective

that

among

his

12 patients,

75%

experienced

complete resolution of their

radiculopathy

and 50%

of patients, long-term follow-up imaging demonstrated complete regression of the lumbar facet synovial cyst

.

Although

results

are variable and the

significant

failure

rate,

this

gesture

can

usually

pass

a course of acute pain. In

most cases, the improvement made possible the resumption of professional activity or at least allows

to

establish

the normal posture (1)(4).

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In our case, CT-guided percutaneous infiltration, has enabled us to confirm the diagnosis, and treat the

cyst

,

which

allowed

an

immediate

relief of pain

without

recurrence

after

a

decline

of

three

years

.

J.F.Martha et al.(1) Have a large

series

of 101 injections

with

rupture of the

cyst

showed

an

immediate

analgesic

effect in 80% of cases and stressed that the infiltration allowed to postpone surgery in half of cases and

follow

up to 3

years

showed

an

analgesic

effect

the

same

on

both

therapeutic

.

Complications of

facet

infiltrations in the

lumbar

spine

are rare,

shared

with

corticosteroid

infiltrations to

other

sites

such

as

risks

of infection or local

hematoma

(1)(4).

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In the study by Allen et al.(2) Another alternative of treatment is the under fluoroscopics percutaneous

contrast

distention

, and rupture of the

lumbar

Z-joint

cyst

,

it

can

expect

about a 70% chance of a

successful

long-

term

outcome

.

Recurrence

rate

is

high

(37.5%) and

usually

occurs

in the first 3

months

.

However

, patients still have a 45% chance of a successful outcome after the second cyst rupture.The advantage

of CT over

fluoroscopy

is

the direct

treatment

of synovial

cysts

as

well

as ganglion,

posterior

longitudinal ligament, and

ligamentum

flavum

cysts

that

do not

communicate

with

the

facet

joint,

therefore

allowing

direct,

safe

, and

reliable

puncture

of the

cyst

without

dural violation

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conclusionArthrography of the facet joint, supplemented by intra-articular injection of corticosteroids, is the last step of medical management, it’s simple to perform, useful to confirm the diagnosis, may provides complete or significant regression of radicular symptoms, and may be an alternative to surgical excision of the cyst.

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ReferencesMartha JF, Swaim B,Wang DA,KimDH, Hill J, Bode R, et al. Outcome of

percutaneous

rupture of

lumbar

synovial

cysts

: a case

series

of 101 patients.

Spine

J

2009;9:899-904.

Allen TL,

Tatli

Y, Lutz GE.

Fluoroscopic

percutaneous

lumbar

zygapophyseal

joint

cyst

rupture: a

clinical

outcome

study

.

Spine

J

2009;9:387-95.

El Shazly AA, Khattab MF. Surgical excision of a Juxtafacet cyst in the lumbar spine: A report of thirteen cases with long-term follow up. Asian J Neurosurg 2011;6:78-82Anthony Chang. Percutaneous

CT-Guided Treatment of Lumbar Facet Joint Synovial Cysts.

HSS Journal

5:2, 165-168.

Bureau NJ, Kaplan PA, Dussault RG.

Lumbar

Facet

Joint Synovial

Cyst

:

Percutaneous

Treatment

with

Steroid

Injections and

Distention

-

Clinical

and Imaging

Follow

-up in 12 Patients.

Radiology

2001;221:179-185.

C

Parlier

-

Cuau

; M

Wybier

; R Nizard; P Champsaur; P Le Hir; J D Laredo.

Symptomatic

lumbar

facet

joint synovial

cysts

:

clinical

assessment

of

facet

joint

steroid

injection

after

1 and 6

months

and long-

term

follow

-up in 30 patients.

Radiology

1999;210(2):509-13.

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THANX